Final 18-Month Results

Volume 4 January 2019

FINAL 18-MONTH RESULTS

1 “WE MUST REMEMBER THAT ONE MAN IS MUCH THE SAME AS ANOTHER, AND THAT HE IS BEST WHO IS TRAINED IN THE SEVEREST SCHOOL.” – THUCYDIDES

2 TABLE OF CONTENTS

1 Executive Summary 5 Assessment Of Data/Program Evaluation 8 Outcomes Of 18-Month Program Evaluation 10 18-Month Program Evaluation Report

The PATHH To Posttraumatic Growth: 17 Warrior PATHH Students Share Their Stories

23 Military Psychologist Article 30 18-Month Results 58 Qualitative Feedback

Contact information: Josh Goldberg 33735 Snickersville Turnpike Bluemont, VA 20135 (972) 975-7488 [email protected] www.bouldercrestinstitute.org EXECUTIVE SUMMARY Since the attacks of September 11, 2001, more than 2.8 million men and women have deployed to war zones across the globe, serving with honor, courage, commitment, loyalty, duty, respect, integrity, and excellence. The post 9/11 conflicts, which represent the longest stretch of war in American history, have taken a tremendous toll in terms of both visible and invisible wounds. It is estimated that more than 30 percent of these remarkable Warriors are struggling with PTSD (a clinical diagnosis received from a mental health professional) or combat stress (struggling with the same symptoms but lacking an official diagnosis). We have now lost more brave souls to suicide at home than on the battlefield, and the suicide rate has grown every year since 2002.

In September 2013, we opened Boulder Crest Retreat Virginia with one objective in mind – to ensure that combat veterans and their families had what they required to live great lives – full of passion, purpose, growth, connection, and service – here at home. Our first nine months were dedicated to learning and understanding the nature and effectiveness of current approaches, and identifying gaps. We hosted a number of clinical and non-clinical programs, attended conferences, and had countless meetings with experts from across the trauma, PTSD, and military psychology fields. What we heard – time and again – was that nothing was working. Nothing was allowing combat veterans to thrive at home. The treatments they did receive – normally a combination of pharmacology and psychotherapy – seemed to temporarily diminish some of the more overwhelming symptoms of PTSD and combat stress, but could not offer a springboard to a great life at home. In short, the message was clear: the best that struggling combat veterans and their family members could hope for was lives as diminished, and often medicated, versions of themselves.

Beginning in May 2014, we began work on a new and innovative program – Warrior PATHH – to address the shortcomings of the status quo and ensure that combat veterans could thrive at home. Warrior PATHH represented the first-ever program designed to cultivate and facilitate Posttraumatic Growth (PTG) amongst the military and veteran community. PTG is a decades- old science that provides a framework for transforming times of deep struggle into profound strength and lifelong growth.

“BOULDER CREST RETREAT ACTS AS A LABORATORY FOR EXPLORING THE EFFECTIVENESS OF ALTERNATIVE APPROACHES TO HELPING VETERANS AND THEIR FAMILIES ACHIEVE POSTTRAUMATIC GROWTH.” DR. RICHARD TEDESCHI AND DR. BRET MOORE, THE MILITARY PSYCHOLOGIST, 2016

1 After more than four years of hard work on Warrior PATHH, five things are clear:

1. The current approach to mental health is not working. These are not our words, but the expert opinions of luminaries from the mental health community. Dr. Thomas Insel, former director of the National Institute of Mental Health, recently asked, “Are we somehow causing increased morbidity and mortality with our interventions?” In August 2015, The Journal of the American Medical Association (JAMA) declared that “new innovative and engaging approaches for the treatment of PTSD are needed.” These words were echoed in the January 2017 edition of JAMA Psychiatry, which stated that “These findings point to the ongoing crisis in PTSD care for service members and veterans. Despite the large increase in availability of evidence-based treatments, considerable room exists for improvement in treatment efficacy, and satisfaction appears bleak based on low treatment retention…we have probably come as far as we can with current dominant clinical approaches.”

”WE HAVE PROBABLY COME AS FAR AS WE CAN WITH CURRENT DOMINANT CLINICAL APPROACHES.” JAMA PSYCHIATRY, 2017

2. The struggles that combat veterans experience in the aftermath of war often relate far more to what they are coming home to (society and peace) than what they are coming home from (war). The same training that ensures Warriors thrive on the battlefield can become problematic on the home front. In order to address this challenge, combat veterans require TRAINING to learn how to translate their valuable skills at home and regain the capacity to regulate their thoughts, feelings, and actions.

3. Combat veterans represent the strongest and finest among us. These Warriors possess skills, strengths, and abilities that are seldom seen and desperately needed here at home. This notion is best captured in the words of Thucydides, an Athenian General and historian, who famously wrote the History of the Peloponnesian War: “We must remember that one man is much the same as another, and that he is best who is trained in the severest school.”

4. When we provide combat veterans with the opportunity to take a knee and receive training that allows them to harness their strengths and abilities at home, they can live the great lives they deserve – full of passion, purpose, and service.

5. Times of deep struggle, and even despair, can serve as the gateway to a life that is authentic, fulfilling, and purposeful. This idea – that what does not kill you can in fact make you stronger – is the basis of Warrior PATHH, and is derived from the science known as Posttraumatic Growth (PTG).

2 In 2015, two world-class psychologists – Dr. Richard Tedeschi and Dr. Bret Moore – agreed to evaluate Warrior PATHH. The two psychologists reported that the progress they were witnessing was unheard of, and began reflecting on how to assess the effectiveness of the program with a view towards ensuring it could become an evidence-based standard.

“IN JUST TWO DAYS, PATHH MAKES BREAKTHROUGHS THAT WOULD TAKE THE AVERAGE MEDICAL MODEL 12-14 MONTHS.” DR. BRET MOORE, TWICE-DEPLOYED FORMER ARMY PSYCHOLOGIST

Given their observations, and in particular Dr. Moore’s statement that: “In just two days, PATHH makes breakthroughs that would take the average medical model 12-14 months,” the next step was clear: we must develop the nation’s first-ever curriculum designed to cultivate and facilitate Posttraumatic Growth amongst combat veterans. This curriculum would enable Warrior PATHH to be codified, documented, proven, and most significantly, scaled to help combat veterans from across the country and possibly the world.

In January 2016, the Marcus Foundation invested $1.05 million to make this vision a reality. This investment focused on two areas of work: the development of the curriculum, inclusive of the Warrior PATHH Instructor Guide, Warrior PATHH Student Guide, Warrior PATHH Journal, Warrior PATHH Syllabus, and Warrior PATHH Schedule of Events; and an 18-month program evaluation of four pilot programs, conducted by Drs. Tedeschi and Moore, to assess the effectiveness and impact of Warrior PATHH.

The 18-month program evaluation is now complete, and the results provide quantitative evidence of what we know to be qualitatively true: Warrior PATHH doesn’t only reduce symptoms substantially; it enables students to live the great lives they deserve here at home. Warrior PATHH unlocks the value of military training and combat experience, and allows combat veterans to be the calm, connected, and congruent leaders desperately needed in their families, communities, and country.

At the heart of what makes Warrior PATHH successful and differentiates the program from the status quo approaches is best reflected in the words of Goethe: “If we treat people as they are, we make them worse. If we treat people as they ought to be, we help them become what they are capable of becoming.”

3 “IF WE TREAT PEOPLE AS THEY ARE, WE MAKE THEM WORSE. IF WE TREAT PEOPLE AS THEY OUGHT TO BE, WE HELP THEM BECOME WHAT THEY ARE CAPABLE OF BECOMING.” GOETHE

This report was created to share the results of the 18-month program evaluation, and in the hopes of catalyzing a discussion about our current mainstream PTSD treatments. It is clear from our experiences and successes, the articles in the Journal of the American Medical Association publications, and the words of combat veterans that we need a new, innovative, and effective approach that allows people to thrive, not simply survive. Warrior PATHH is that new approach – and the pages that follow demonstrate precisely why that is true.

When we send men and women to war, we make a special covenant with them. In exchange for their service and sacrifice, we pledge to bring them home – all the way home. As a society, we are failing to honor that commitment. We can and must do better.

We must never forget that combat veterans possess strengths, skills, and abilities that are seldom seen and desperately needed here at home. It is our responsibility to understand how to harness those strengths and abilities, and enable this remarkable community of heroes to be as productive at home as they were on the battlefield. That is why we created Warrior PATHH, why we acquired Boulder Crest Retreat Arizona in May 2017, why we are supporting efforts to implement Warrior PATHH in communities across the country, and why we are inviting you to join us.

Together, we can unlock the potential of America’s Next Greatest Generation.

Josh Goldberg Co-Founder and Executive Director Boulder Crest Institute for Posttraumatic Growth Author, Struggle Well [email protected]

4 ASSESSMENT OF DATA/PROGRAM EVALUATION Dr. Richard Tedeschi and Dr. Bret Moore

The data support Boulder Crest’s belief that Warrior PATHH is improving the psychological health of veterans battling posttraumatic stress disorder and other psychiatric conditions. Results from traditional clinical self-report measures (e.g., PTSD Checklist for DSM- 5, Depression Anxiety Stress Scale-21, Insomnia Severity Index) embedded within the program evaluation reveal robust improvements in clinical symptoms. Moreover, these improvements are consistent with improvements seen in traditional outpatient healthcare systems (e.g., VA clinics), and in some cases, surpass these same metrics.

PTSD SCORES ARE REDUCED BY 54% AFTER COMPLETION OF WARRIOR PATHH. MOST IMPRESSIVELY, SIGNIFICANT GAINS ARE MAINTAINED AT EIGHTEEN MONTHS.

The same is true for depression, anxiety, and stress. At eighteen months after completion of Warrior PATHH, participants show sustained improvements of 52% for depression, 41% for anxiety, and 35% for overall level of stress. Clinically significant improvements are also seen for insomnia with a 39% reduction in sleep disturbances eighteen months following completion of Warrior PATHH. Results also reveal that veterans are showing substantial increases in developing and maintaining positive emotions (e.g., joy, inspiration, pride) while reducing negative emotions (e.g., guilt, irritability, nervousness).

A unique aspect of Boulder Crest’s Warrior PATHH program is the emphasis on teaching veterans to live well and how to use their difficult life and combat experiences to thrive. After completion of Warrior PATHH, the data reveal that veterans are better able to effectively manage a variety of life stressors, develop a greater flexibility and adaptability in order to more effectively manage life’s adversities, and foster healthier interpersonal relationships.

THE DATA ALSO SUPPORT THE MAIN PURPOSE OF WARRIOR PATHH, WHICH IS TO PROMOTE POSTTRAUMATIC GROWTH. WARRIOR PATHH PARTICIPANTS REPORT AN INCREASE IN POSITIVE SPIRITUAL/EXISTENTIAL CHANGES BY 78%, IMPROVED RELATIONSHIPS BY 69%, NEW POSSIBILITIES BY 58%, AND PERSONAL STRENGTH BY 36%. ON AVERAGE, PERSONAL GROWTH OVER THE EIGHTEEN MONTHS FOLLOWING THE WARRIOR PATHH PROGRAM IS 56%.

5 Due to the fact that traditional veteran mental healthcare systems do not measure psychological growth on a routine basis, it is difficult to make any direct comparisons. However, based on research in the civilian population, these changes are impressive and Boulder Crest should be commended for addressing this aspect of veteran psychological health and their success in promoting it in those who complete the program.

We believe there are several therapeutic processes within the Warrior PATHH program that lead to the identified improvements in clinical symptoms, stress management, and psychological growth. First, Boulder Crest and Warrior PATHH staff create a respectful, empathic, and non- judgmental atmosphere which promotes personal reflection, self-disclosure, and connection with others. The relationship that Boulder Crest staff builds with participants is similar to the relationship that is formed in psychotherapy, which, according to “common factors theory,” is believed to be the most important factor in all effective psychotherapies.

Second, Warrior PATHH incorporates practices which have been shown in clinical research to be effective for a variety of populations and conditions. A few examples include meditation and mindfulness, psychoeducation, stress management, and self-disclosure. Moreover, the program includes a variety of wellness practices that are based in science found within the areas of recreational therapy, nutrition, and physical fitness. And last, unlike traditional mental health models, Boulder Crest provides substantial aftercare as part of their 18 month follow-up program.

We also think it is important to note that most of the current mental health care systems only measure symptoms and fail to recognize the complexity of psychological health in general and of veterans specifically. A significant limitation of our current systems of care is that they focus on symptomology.

Although reducing clinical symptoms (low mood, hyperarousal, nightmares) is important, the reality is that even after successful treatment with psychotherapy and/or medication, symptoms will continue for many. This narrow and reductionistic approach to psychological health lessens the likelihood that growth will occur and increases the likelihood that the veteran will need to accept a diminished version of themselves. We believe this does little to honor the sacrifices of veterans and embraces a “good enough” mentality when it comes to caring for the men and women who have served our Nation.

WARRIOR PATHH PARTICIPANTS ARE ABLE TO REACT TO LIFE STRESS IN HEALTHIER AND MORE PRODUCTIVE WAYS AND THEY ARE EXHIBITING SIGNIFICANT LEVELS OF POSTTRAUMATIC GROWTH.

6 Overall, program evaluation data reveal that Warrior PATHH participants experience dramatic improvements in PTSD, depression, and anxiety. Warrior PATHH participants are able to react to life stress in healthier and more productive ways and they are exhibiting significant levels of posttraumatic growth. Warrior PATHH participants are less critical and more compassionate with themselves. Warrior PATHH is well tolerated, and unlike some evidence-based psychotherapies and medications, the program has a very low dropout rate.

SINCE BOULDER CREST HAS DEVELOPED THOROUGH, LOGICAL, AND EASY-TO-FOLLOW STUDENT AND FACILITATOR GUIDES, WE BELIEVE THESE RESULTS CAN BE REPLICATED ELSEWHERE.

Furthermore, since Boulder Crest has developed thorough, logical, and easy-to-follow student and facilitator guides we believe these results can be replicated elsewhere if fidelity of the current PATHH program is maintained and additional tools like myPATHH are implemented.

Dr. Richard Tedeschi, Ph.D., is a licensed psychologist and Professor Emeritus at UNC Charlotte where he was core faculty for the Health Psychology Doctoral Program, teaching Ethics and Professional Issues, Psychological Treatment, and supervising doctoral students in their research and clinical practicum work. He has published numerous articles and books on the concept of posttraumatic growth that he helped to develop. He serves as media consultant on trauma for the American Psychological Association and is a Fellow of the Division of Trauma Psychology and has provided presentations and training on trauma for the U.S. Army, and many professional organizations, clinics, and educational institutions.

Dr. Bret A. Moore, Psy.D., ABPP, is a prescribing psychologist and board-certified clinical psychologist in San Antonio, Texas. He is a former active duty Army psychologist and two-tour veteran of Iraq. He is the author and editor of 16 books, including Treating PTSD in Military Personnel: A Clinical Handbook, Wheels Down: Adjusting to Life after Deployment, and Taking Control of Anxiety: Small Steps for Overcoming Worry, Stress, and Fear. He writes the biweekly column Kevlar for the Mind, which is published in Army, Navy, Air Force, and Marine Corps Times. He has also written feature articles for Scientific American Mind and The New Republic. Dr. Moore is a Fellow of the American Psychological Association and recipient of the Arthur W. Melton Award for Early Career Achievement in Military Psychology from Division 19 and the Early Career Achievement Award in Public Service Psychology from Division 18 of APA. His views on clinical and military psychology have been quoted in USA Today, The New York Times, and The Boston Globe, and on CNN and Fox News. He has appeared on NPR, the BBC, and CBC.

7 OUTCOMES OF 18-MONTH PROGRAM EVALUATION After 18 months of comprehensive program evaluation into Warrior PATHH, it is now clear that Warrior PATHH is far more effective than current approaches to PTSD, anxiety, depression, and suicidality. It is also clear — and a key element of the culture of Boulder Crest — to recognize that we can always do better to ensure that our nation’s Warriors can thrive at home, and transform deep struggle into profound strength and lifelong growth. To that end, we have identified four actions that we will take based on the 18-month program evaluation: INVESTIGATE AREAS FOR FURTHER IMPROVEMENT AND ENHANCEMENT OF WARRIOR PATHH

With the program evaluation complete, we will leverage the incredible amount of data collected on the effectiveness of Warrior PATHH at different time periods to determine how to improve and enhance Warrior PATHH. This will represent a major step towards the development of Warrior PATHH Version 3.0.

LAUNCH myPATHH APPLICATION

To support students during their 18-month journey at Warrior PATHH, we have partnered with Accenture Federal Services to develop a mobile web application — myPATHH. myPATHH enables students to document their answers to critical questions about their life; connect with fellow team members and the broader Warrior PATHH community; set and track goals; and learn from a broad range of content that is created and curated by Warrior PATHH guides and advisors to Boulder Crest. myPATHH supplements the Warrior PATHH Student Guide and Warrior PATHH Journal, and importantly, provides students with the ability to access content whenever they want.

8 IMPLEMENT WARRIOR PATHH PROGRAM EVALUATION 2.0

With the 18-month program evaluation completed, there is now a robust body of evidence demonstrating the effectiveness of Warrior PATHH. The next step in terms of program evaluation is to develop a measurement approach that continues to add to this data while also providing a more granular understanding of the impact of each component of Warrior PATHH. Warrior PATHH Program Evaluation 2.0 — will look at symptoms, quality of life improvement, and Posttraumatic Growth, while expanding to the topic of knowledge acquisition, specific to the integration of myPATHH.

BUILD OUT THE PATHH PARTNER NETWORK

A key driver for the development of the Warrior PATHH curriculum, and the 18-month program evaluation, was to create and demonstrate a proven approach to PTSD and combat stress that could be scaled nationally. We have long envisioned a PATHH Partner Network — comprised of Boulder Crest Retreat Arizona and Boulder Crest Retreat Virginia, along with eight partner organizations from states across the country — that could create a community of innovation, support, training, and most importantly, provide what struggling Warriors deserve and require. The completion of the 18-month program evaluation, alongside the curriculum and the launch of myPATHH, create a compelling package that has intrigued and interested organizations across the country. We are leveraging this interest to begin building the network, while also finalizing our Warrior PATHH Train-the-Trainer program, ensuring that Warrior PATHH is delivered with fidelity at every location.

9 18-MONTH PROGRAM EVALUATION REPORT Background The Warrior PATHH 18-month program evaluation is comprised of 250 questions across 24 measurement tools, and students are surveyed prior to attending Warrior PATHH, following the 7-day initiation, and at the 30-day, 90-day, 180-day, 1-year, and 18-month marks.

For the purpose of context, it is worth noting that most veterans receiving VA PTSD treatment (usually 12-15 weeks of Prolonged Exposure or Cognitive Processing Therapy) will be surveyed using the Posttraumatic Stress Disorder Checklist (PCL) before the start of treatment, at several points during treatment, and then at the conclusion of treatment. Ultimately, it is the responsibility of each clinician to monitor progress. While data is deposited into a large VA data mining database, studies of treatment efficacy to the scale and scope of the Warrior PATHH longitudinal program evaluation are rare.

About Program Evaluation Program Evaluation (PE) is the systematic application of scientific methods to assess the design, implementation, improvement or outcomes of a program (Rossi & Freeman, 1993; Short, Hennessy, & Campbell, 1996).

Purposes for Program Evaluation include: • Demonstrate program effectiveness to funders and document program accomplishments. • Improve the implementation and effectiveness of programs. • Better manage limited resources. • Justify current program funding and support the need for increased levels of funding. • Satisfy ethical responsibility to clients to demonstrate positive and negative effects of program participation. • Document program development and activities to ensure successful replication.

10 Areas of Evaluation The comprehensiveness of this program evaluation is not the only noteworthy aspect of the curriculum project; it also takes a holistic approach to wellness, success, and struggle, and evaluates the effectiveness of Warrior PATHH in three key areas: Symptom Reduction (the sole focus area for most clinical studies), Quality of Life and Stress Management Improvements, and Posttraumatic Growth achieved.

Symptom Reduction This domain measures the presence and/or degree of symptoms associated with psychiatric disorders. Measures assess posttraumatic stress disorder, depression, anxiety, insomnia, alcohol and drug abuse/dependence, and suicidal thinking. The symptom-based measures utilized are the ones often used in traditional military and Veterans Administration clinic settings. The rationale for including this domain in the evaluation is so that it can be determined if this particular non-clinical program improves symptomatology associated with formal psychiatric disorders. If so, there is evidence showing that the Warrior PATHH approach to Warrior care may be comparable to traditional mental health clinical programs.

Quality of Life/Stress Management The quality of life domain measures the degree to which military members and veterans experience an enhanced quality of life as a result of attending the Warrior PATHH program. The existing and novel measures within this group look specifically at health, finances, employment satisfaction, relational functioning, social support, and perceived stress. Most traditional clinics do not evaluate this aspect of their client/patient functioning; they generally stop at the clinical domain — assessment of presence and severity of clinical psychiatric symptoms. In essence, regarding the second PE domain, the goal is to assess the less well-defined construct of “living well”. This is where Boulder Crest provides a sharp distinction between its Warrior PATHH program and what is offered by traditional clinical programs.

Posttraumatic Growth & Cognitive Flexibility The third assessment domain of the Warrior PATHH PE is what makes Boulder Crest truly unique. Boulder Crest has adopted a unifying theme for its various programs which is posttraumatic growth (PTG). PTG is a concept that has been articulated and researched extensively by Drs. Richard Tedeschi and Lawrence Calhoun. The overarching principle is that from loss there can be gain and that people can become stronger, better, and wiser as a result of their difficult life experiences. Consistent with the aims of the Warrior PATHH program, a number of measures dedicated to assessing growth have been included in the program evaluation. To this end, measures assessing growth, resilience, flexibility in thinking, and gratitude are included in the PE. To date, there do not appear to be any programs similar to Warrior PATHH, or traditional clinical programs for that matter, with the stated purpose of measuring PTG.

11 Data Reviewed for Program Evaluation Participants from eight Warrior PATHH programs are included in the program evaluation data, inclusive of six male programs and two female programs, for a total of 49 respondents. The survey response rate was 95 percent across all collection points.

SURVEY COMPLETION SCHEDULE WP # Initial 7 Days 30 Days 90 Days 180 Days 1 Year 18 Months WP 017

PILOT WP 018 PROGRAMS WP 019 (n=23) WP 020 (Female)

WP 021 (Female) ADDITIONAL WP 022 PROGRAMS WP 024 (n=26) WP 025

12 DEMOGRAPHICS OF WARRIOR PATHH PARTICIPANTS IN 18-MONTH PROGRAM EVALUATION

LOCATION

2-4

5-10

10+

AGE BRANCH 30 30 20 20 10 10 0 0

20-29 30-39 40-49 50-59

AIR FORCE NAVY MARINE CORPS ARMY

MARITAL STATUS EMPLOYMENT Married/Engaged Single Divorced/Separated 23 16 10 35 Employed/School LIVING ARRANGEMENT Lives Alone 17 14 Lives with Spouse, Partner, and/or Children 32 Retired/Not Working

13 14 15 16 THE PATHH TO POSTTRAUMATIC GROWTH: WARRIOR PATHH STUDENTS SHARE THEIR STORIES

Name: Brandi M.

What was it like at Warrior PATHH? I went to a few counselors after I left the military to better understand the issues I was facing, but this was the first retreat I had ever been to and first multiple day session. I really had no idea what to expect there but my experience in talking to civilian counselors always left me with a feeling of not being understood. Civilians were very sympathetic to what I had been through but couldn’t relate to me, so they either came across as not understanding or they over sympathized giving me the feeling that the things I had been through were a lot for anyone to deal with and it was ok that I couldn’t get over them. I remember the very first day talking with Dusty and Coach and just seeing these big, hard-core guys and hearing their stories and seeing that they were ok to talk about the bad stuff but they weren’t using it as an excuse to not live life to the fullest either. They had somehow found a way to turn the “disorder” of post-

B ratraumatic n d i stress into a time of growth. I really didn’t know what to expect during my time there but just hearing the staff talk on the first day there about their own path in this journey told me their experience was valid and I knew I was going to learn a lot.

What happened during your time at Warrior PATHH? BCR shows you real-life examples of ways to deal with the stress of life that most of us have come to know as PTSD. We talked about breathing techniques, equine therapy, meditation, archery and several other methods. Everything we talked about and practiced brought new ways of thinking about negative emotions. Some of the experiences were so tangible though and I think that was the real break through for me. I recall a few of those moments so distinctly. One was in archery. This was not a session I thought would be that influential, but I was looking forward to it as an outdoor nature lover. I never would have guessed the impact it had on me though. We were given some quick instruction with the bow and given time to breathe and relax and pull the string and focus. I had done archery before so I was expecting to do ok hitting the target. Then we went back to the line and as I started pulling the string back, one of the trainers asked me how things were going since my divorce. As I started talking, I lost all focus and concentration and the arrow didn’t even hit the target. We did a few rounds like that, showing us that when we got off track and start thinking about the bad, we can’t focus on what’s ahead. Our body also physically reacts to stress. When stress affects our heart beat, our breath, our nervous system, the physical impact completely affects our focus. It was an amazing example.

17 I learned TM from trained professionals and experienced moments of true peace. The more we practiced throughout the week, the more moments I got to have. I left there thinking why would I ever NOT want to have this peace in my day and I haven’t stopped in 18 months. Another huge take away for me was about a Native American story of two wolves fighting inside us. One is evil, anger, jealousy, hate, guilt, sadness. The other is joy, peace, patience, kindness, integrity. A young boy asked which wolf wins and the grandfather replied, the one you feed. This came up several times during our week as we had example after example of things going wrong in our lives and we could clearly see where we were feeding the bad wolf. I would have never known I was even doing that but I learned how to recognize it and that which one I feed is entirely my choice.

Most importantly, I learned forgiveness. After walking the labyrinth with heavy equipment and then letting that go, I physically felt the weight of many things that had been on my heart for years just leave me. I left so much in the middle of that circle and learned to forgive a few key people in my life and learned to forgive myself. Learning to let go was a huge victory in my life journey and I learned it at BCR.

Finally, I learned it’s not what’s wrong with us, it’s what happened to us. This has been very helpful as many of us have been diagnosed with this disorder…that we’re messed up, not whole, damaged. We all talked through our old story and we left them there in a fire pit at BCR. Those old stories no longer serve us and we can choose how the ending will be.

What it your life like now? Today, 18 months later, I’m me. I’m back to the person I was created to be. A mom dedicated to raising strong and healthy daughters. A leader focused on my work and making every day the best it can be for everyone I work with. I am strong enough to be in a healthy relationship and not lose myself in it. I am a free soul … free to focus on what I want in this life and have control over my own thoughts. I have freedom and power to give energy to the things that serve me. I have the choice every single day of feeding the good wolf and feeding the bad.

Our group that went through BCR together is still connected in group chats and we check in on each other all the time. All of us are still connected to the staff and follow each other on social media. Having these folks as part of your life network is like paying some life coach to build you up and keep you strong. I am so lucky to have met every single one of them.

My life now is about what’s ahead, not what’s behind. I am making choices daily to keep practices in my life that work for me like meditation, exercise, nutrition, art, etc. It takes a lot of work and that’s what BCR taught us, that training involves discipline and consistency and we have to train ourselves how to deal with stress. BCR taught us that life isn’t hard, but it is hard work. The program and staff at BCR gave me a do-over, a whole new start. I’m now equipped for the challenge and beyond thankful!

18 Name: Andy K.

What brought you to Warrior PATHH? After retiring in 2009 I found myself very lost and confused but unable to accept or want to accept help. I had had multiple operations and found myself on pain pills, anti-depressants and other meds…and just searching for something. I decided, without input from my family, to move to the middle of nowhere. I was angry at everything. I had distanced myself from all family and friends and was spiraling very fast to the end.

I had a friend take his life one day in 2015 which left me emotionally paralyzed and blank to the world. As the universe works, Josh Goldberg (then Boulder Crest’s Director of Strategy) came to

Andy brief the company I was working for. I was intrigued and went through the intake process and was accepted into the 007 Warrior PATHH program. I was still in denial about needing to go, but when I left my brothers in the 007 class I knew that I had made the best choice for my family and myself.

What is your life like now? Since leaving BCR I have started a non-profit called Checkpoint One. I’ve become an Equine Specialist and a yoga teacher. I’ve become a husband, a father and a son again. I teach yoga at the VA…and I wake up every morning knowing that when I get out of bed and can start my day, I have a notch in the “win” column…and I struggle well.

Name: Kathryn B.

What brought you to Warrior PATHH? I am dual-military and deployed with my husband Jonathan (we were not located in the same areas, but did see each other twice), who experienced much more trauma than me and changed significantly from that experience with untreated PTSD. I think deployment innately changes you, but the months/years following I felt beat down with suppressing the emotional toll from deployment (my experience was not as horrible as another’s, so I felt I had no place talking about it) and trying to wear multiple hats (a supportive wife, a “battle buddy” because I understood what he was going through, a receiver of his uncontrolled anger, a geo-bachelor [we were stationed apart on top of multiple TDYs]), while still pushing myself to be successful at work and therefore buried my own issues/struggles. At work, I was engaged and successful, but at home, I fought everyday with my husband (we went to counseling, slept in separate rooms, began to file for divorce) and pulled away/disconnected from nearly all friends. I spent money

Kathrynon frivolous things because I needed instant gratification and worked myself to the max to stay busy because I refused to allow myself any downtime or process. I couldn’t shut off my thoughts and would wake a dozen times in the night and struggle to fall asleep, so I was taking Benadryl with melatonin at night and drinking energy drinks during the day. When stress and anxiety

19 would overwhelm me, which occurred more and more frequently, I resorted to bulimia because I could hide it and it wasn’t illegal, like drugs, or harming anyone else, like alcohol, or looked down upon, like infidelity. This was my go-to coping mechanism in high school, college, and here it was again during deployment and the years following and it was crippling and brought immense shame.

When the Army selected me to go to graduate school in 2016, I realized I had changed A LOT in the 6 short-years since I finished undergrad and assimilated back into “civilian” life as student (still on Active Duty, but my “job” was to go to school, so I felt/looked like a civilian). I was valedictorian in High school and Summa Cum laude in college, so I thought this would be my chance to take a knee...but I was having a horrible time adjusting. I couldn’t concentrate on homework/studying and was mediocre my first two semesters and stressed to tears. I couldn’t connect with my peers and never made an effort to get to know them (why waste time on relationships that won’t last or were surface level). I couldn’t enjoy being on campus or feel empathy for others because I was cynical and had lived in the “real world.” In September 2017, I went to a wedding (alone) and realized the time was now to file for divorce because nothing was changing in our marriage and I was miserable. The final straw was when I ran the Las Vegas Rock n Roll Half Marathon in November 2017 and had a horrible panic attack (shaking, tears, then hyperventilating that a police officer pulled me out of the crowd). The race was only a few weeks after the mass shooting, so the race scene was saturated with helicopters flying overhead, SWAT, heavily armed security in towers, and security checkpoints, which created a horrible bottle neck that I was trapped in a mob of angry people pushing, shoving, yelling, while getting separated from my younger sister in the 30,000+ crowd. When I met up with her after the race, she was beaming with excitement and I felt totally dejected and realized I was truly alone in my struggle and did not want to experience life this way anymore and applied to the Warrior PATHH program.

What happened at Warrior PATHH – and what has life been like since? Since leaving BCR in January 2018, I have felt a weight lifted off of my shoulders. Having the support system, weekly check ins, and TM have allowed me to continue to implement positive coping mechanisms and establish new patterns of behavior/practices. The concept of PTG so resonated with me that I have felt empowered to do things that I would have ether never attempted or struggled through had I not attended PATHH: • I have not relapsed with my eating disorder and do not obsessively track macros/restrict or binge food. I truly see food as fuel and am much more appreciative of what my body can do versus what it may look like. • I fight with my husband significantly less. He still has his own struggles and we are not perfect, but I do notice that on days I do not meditate, an argument ensues. I truly feel I was stuck in that feeling on wanting conflict and often contributed to escalating an argument than diffusing one.

20 • I cutout Monster Zeros and Benadryl, but do still sometimes use melatonin. However, I do notice I can fall asleep much faster, wake less often, and feel rested (versus groggy) when I wake up. • I traveled to Germany for a 2-week exchange program through UNC in March; I did not allow my anxiety over having no control over my day or worrying about an attack to prevent me an enriching experience. • I have always wanted to coach others in fitness, but lacked the confidence to do so because I felt that an introverted person does not make for a good coach. PATHH helped me see that pulling away from others was a coping mechanism. Accordingly, this Spring, I obtained my Group Fitness Instructor certification, Crossfit Level 1, and TRX Suspension and Functional training certifications with the intent of coaching soon. • I have reconnected with a few close friends (meeting for lunch, going to their baby shower, being the first to engage a text message) and have truly missed that connection with others. • I finished my master’s paper ahead of time and graduated UNC; I feel energized and excited to return to my job in the Army as a different person than who started school two years ago.

Name: Miguel R.

What brought you to Warrior PATHH? I attended Warrior PATHH out of recognition that what I have been doing to address my challenges was not working. While I was extremely skeptical of some of the practices I heard of in advance, I recognized that I needed something different and committed maintaining an open mind. But most of all, I attended Warrior PATHH to find the healing that had been elusive for too long.

What happened at Warrior PATHH? The single most important thing that happened at Warrior PATHH was that I rediscovered a huge component of my identity. The Warrior PATHH program coupled with its execution from an authentic staff reminded me that someone cared. If they, not knowing me, cared enough to pour their time and experiences into my life, I had to reciprocate and pour work into my own life. This message was accentuated when the founder retold a story in which he told a fellow Miguel service member that only one can truly save oneself. While I am indebted to the founder(s), the program, and the staff for instilling hope for my future, I learned that posttraumatic growth is a feasible outcome – one that I own.

What is life like now? There are good days and there are bad days; however, I have practices that take the sting out of the bad days, enhance the good days, and provide a glimmer of hope for tomorrow. As important, I can look in the mirror and remind myself that I am a soldier and a warrior and owe it to myself and my tribe to keep on keeping on.

21 John W. What brought you to Warrior PATHH? I found myself going down a dark path with alcohol as a temporary solution to a long term demon called anxiety. The events that have occurred in my life left it spiraling out of control and after many years of trying to control it on my own and medication, I realized that I was unable to handle it by myself. I needed help because If I were to continue the lifestyle I was on it, it wasn’t going to last much longer.

What happened at Warrior PATHH?

Joh n Words will do no justice in describing my experiences at Warrior PATHH. I learned more about myself and how to deal with my demons in those seven days then I have talking to any doctor, psychiatrist, or psychologist. “It’s not what’s wrong with me. It’s what happened.” The staff never gave up on anyone of us even when we had given up on ourselves. While I was there they taught me the power of meditation. Once I got it down I began to wean off my medication for anxiety. I ended up stopping it and began to live by “Meditate not Medicate.” I didn’t need it any more. Instead of a pill all I needed was twenty minutes twice a day and I would accomplish way more than some pill I have to keep taking.

What is life like now? Life pauses for no one, however, Warrior PATHH has taught me how to deal with my internal issues and ultimately make me realize that I am not this monster I thought I was. I am not nearly as anxious or angry as I usually was. I’ve become more active and have been continuing to focus on making me better every day. I will always have room to improve and I want to ensure I never let an opportunity slip away.

22 e Ocial Newsletter of the Society for Military Psychology Division 19 of the American Psychological Association Volume 33 Number 2 Summer 2018

Boulder Crest Retreat: Integrating Non-Traditional and Traditional Interventions for Military Veterans Richard G. Tedeschi Bret A. Moore University of North Carolina, Charlotte University of Texas Health Science Center, San Antonio

Abstract

This article reviews Boulder Crest Retreat for Military and Veteran Wellness, a community based, non-profit, multisite, private organization based in Bluemont, Virginia. Boulder Crest provides care for veterans dealing with posttraumatic stress through principles of posttraumatic growth. Examples of how various therapeutic components of the organization’s flagship program are provided, parallels between active ingredients of evidence-based therapies and the program are discussed, and recommendations for integrating key aspects of the program into traditional behavioral health care treatments are reviewed.

Although estimates vary, experts generally agree that up to a third of Iraq and Afghanistan veterans battle some form of psychological ailment as a result of their service (Hoge, Auchterlonie & Milliken, 2006; Hoge et al, 2004). More specifically, estimates of the prevalence of posttraumatic stress disorder (PTSD) in these same groups range between 15 to 25% (Hoge, Terhakopian, Castro, Messer, & Engel, 2007; IOM, 2014; Tanielian & Jaycox, 2008). Arguably the most troubling and perplexing psychiatric issue associated with the recent conflicts in Iraq and Afghanistan is the significant increase in suicide ideation, attempts, and completions over the past decade (Rudd et al, 2015).

Research funding and dissemination of evidence-based treatments for psychiatric disorders in veterans has been a major priority for the military and veterans administration health care systems. The most noticeable focus has been on the treatment of PTSD. In this article we discuss how elements of the traditional evidence-based approaches can be integrated with innovative, non-traditional ways to provide better outcomes for veterans suffering from psychological trauma. This kind of integration is being developed at Boulder Crest Retreat in Virginia and Arizona.

23 Success and Failure with Evidence-Based Treatments

According to the recently released Department of Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guidelines for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder (2017), there are several psychotherapies deemed to have sufficient evidence to support their use in the treatment of PTSD with veterans. Those with the highest level of recommendation are “trauma-focused” psychotherapies, which are interventions that require the veteran to actively confront the trauma through talking, imagining or writing about the traumatic event. Although trauma-focused therapies like prolonged exposure, cognitive processing therapy, and eye movement desensitization and reprocessing outperform waitlist and treatment-as-usual controls and result in clinically significant reductions in symptoms, the majority of veterans do not achieve remission. In fact, up to two-thirds of “successfully” treated individuals retain the PTSD diagnosis (Schnurr, 2007; Steenkamp, 2015). In addition to the magnitude of effects, these therapies face the problem of early termination or “dropout” of treatment, which can be as much as 40 percent or higher with particular therapies (Kehle- Forbes, 2016; Schnurr, 2007). And lastly, trauma-focused therapies appear to be only marginally more effective than non-trauma-focused psychotherapies (e.g. interpersonal psychotherapy, acceptance and commitment therapy), questioning the use of these interventions as “first-line” treatments considering their high dropout rates.

If a veteran is not interested in a trauma-focused psychotherapy, or if the therapy is not available, the VA/DoD guidelines (2017) recommend the use of four specific medications to include three selective serotonin reuptake inhibitors (paroxetine [Paxil], sertraline [Zoloft], fluoxetine [Prozac]) and one serotonin norepinephrine reuptake inhibitor (venlafaxine [Effexor]). Even though many more medications are used with veterans battling PTSD and related disorders, the guidelines do not support their use due to lack of research supporting their efficacy or because the risks of these medications outweigh the benefits.

Considering the limitations of psychotherapeutic and pharmacological treatments, it is reasonable to consider other forms of interventions that do not neatly fit within the traditional evidence-based model of care and that are not as readily studied by researchers or have findings published in top-tier peer-reviewed journals. These may be single interventions such as mindfulness, exercise, or relaxation training or programs that combine multiple interventions in a structured and deliberate format. A good example of the latter is Boulder Crest Retreat.

24 Boulder Crest and the Four “P’s”: Philosophy People, Place, & Program

Boulder Crest Retreat for Military and Veteran Wellness (BCR) is a community based, non- profit, multisite, private organization based in Bluemont, Virginia with an additional center in Arizona. The flagship program of BCR, Warrior PATHH (Progressive and Alternative Training for Healing Heroes), uses a variety of complementary and alternative interventions for posttraumatic stress and is based on the concept of posttraumatic growth (Tedeschi & Moore, 2016). Warrior PATHH begins with a seven day onsite residency with an 18 month follow-up program facilitated primarily through web-based sessions with BCR staff members. Preliminary results are encouraging, and it is useful to consider how positive outcomes of the Warrior PATHH program are achieved. There appear to be four essential components that together produce favorable outcomes, based upon data being gathered in an ongoing program evaluation.

Philosophy

The program has a coherence to it because there is a fundamental philosophy that guides the activities in the program and how they are implemented by program staff. The philosophy is based on the posttraumatic growth (PTG) concept. The PTG concept is that traumatic events can often be catalysts for positive change, since the events that create psychological distress by contributing to confusion about self identity, the world and the future also open up opportunities for questioning, exploration, and reconsideration of long-held assumptions about these matters. The result of this process is a rebuilt set of core beliefs that better serve the trauma survivor in accounting for what happened and how to proceed into the future.

The PTG concept provides several ways of understanding trauma and its aftermath that are salutary.

1. There is a sense of possibility for growth in the aftermath of trauma, not simply ongoing struggle with symptoms of PTSD or related disorders. 2. There is a process that can be understood and implemented in order to facilitate PTG. Veterans who have experienced trauma have a path they can travel to be more than PTSD symptoms or people who have overcome symptoms. 3. Veterans who are perceived as having this potential for growth are more likely to be treated with respect and valued. 4. Veterans who understand that PTG is the philosophy underpinning the Warrior PATHH program see themselves as suffering not because of character defects or something else that is wrong with them, but because of what happened to them. This understanding helps to relieve shame and self-stigma from those who are suffering. 5. The PTG model suggests specific domains of growth that can be noted as indicators of progress that give meaning to the experiences of trauma and their aftermath, so that trauma can be tolerated or for some, even valued, since it is no longer meaningless or in vain. 6. The PTG model posits that in order to facilitate PTG, trauma survivors will benefit from

25 expert companionship. Note that the assumption is that PTG can be facilitated, but that the process itself is rather common and naturally occurring without professional intervention. The concept of expert companionship emphasizes that trauma survivors first need companionship, and the companion must be first willing to learn from the trauma survivor about their life and experiences, and not start with taking a position of knowing how that person should live their life. The concept of expert companionship emphasizes that relationship is more important than technical expertise. Therefore, paraprofessionals and partners in the trauma survivorship can be very effective in facilitating PTG.

People

The people who guide the participants through the program embody the concept of expert companionship. With the majority of staff being veterans, there is a quickly developing sense of trust. All staff are involved in respectful interactions with the veterans in the program, including those who are not directly responsible for implementing it. Therefore, the important elements of the people at BCR are the following.

1. They are familiar with the military experience from their own service or from close connections with veterans. 2. They are very good listeners and learners, and approach the veterans in the program with respect and encouragement. They enjoy their work and the energy and fun that shows up in their work relaxes participants. 3. They understand the PTG concept and expert companionship, and therefore do not focus on symptoms. 4. The language used is consistent with a respectful approach with the veterans. They are called “students” rather than “patients” or “clients”, and the staff are “guides” rather than “therapists” or “technicians”. The program itself is referred to as “training” rather than “therapy” as training can be thought of an extension of military life and experience.

Place

Most veterans receive therapy in clinics and hospitals. These environments imply that a disease or disorder is being treated. Often they are institutional and somewhat unpleasant. In contrast, BCR is in a rural setting devoted to the Warrior PATHH program, with buildings and facilities built out of wood and stone in rustic designs. The grounds and buildings are impeccably kept, again demonstrating respect for the participants. The food that is served is healthy and delicious and not at all institutional. The environment is quiet and this provides an opportunity to quiet the mind, as meditative techniques are integrated into the program. A good deal of time is spent outside in the quiet and beautiful environment. There are some data to indicate that activity in natural environments is a healing experience for veterans (Westlund, 2015).

26 Program

The Warrior PATHH program is structured around the PTG intervention model that includes five elements:

1. Psychoeducation about physiological and psychological trauma response and PTG; 2. Emotion regulation training, including meditative techniques; 3. Constructive self-disclosure about trauma and life in the aftermath of trauma; 4. Narrative development that integrates perspectives on life before military service, the experiences of military service, and the aftermath of deployment and service as the veteran returns home; and 5. Missions that could be developed to transmit the learning about the value of life, living courageously, and other understandings to those in society who have not been exposed to these perspectives.

The program incorporates elements that are found in some traditional trauma interventions, but in ways that weave these into experiences that do not appear to be “therapy.” For example, emotion regulation strategies appear throughout the program in such activities as archery, kayaking, or meditation. Disclosure is encouraged throughout but not demanded, and in the bonfire discussions held at the end of each day, there is safety in the calm environment and the simple acceptance and lack of analysis given to disclosures. This way of interacting with program participants helps overcome the reluctance and resistance many might feel, and as a result, the dropout rate over 18 months is extremely small.

The program is designed to develop a small team that will continue to rely on each other for support over at least 18 months of continuing study and support through video conferencing. Therefore, care is shown in this commitment to support and encouragement, and each team member feels a shared obligation to maintain the mutual support that developed during the first week of the program at BCR.

Integration of PATHH elements

The integration of the Warrior PATHH program philosophy with the setting, the program elements and the people who act as guides creates an experience for participants that appears to be unique in the field of trauma intervention. Without any one of these elements, the outcomes are likely to be compromised. However, we believe that the successful components of Warrior PATHH could be integrated into traditional mental health programs.

The setting is likely the element that is most difficult to reproduce, but there may be ways to incorporate some aspects of a calming, natural environment in many settings that do not have the facilities available at BCR. For example, traditional hospital and clinic “campuses” often have dedicated outdoor spaces for patients and guests to relax. These spaces could be incorporated in to care programs for veterans. At a minimum it provides a break from the often impersonal and sterile offices in which veterans typically receive care.

27 Integration of the PTG philosophy into PTSD care for veterans would be less of a challenge. The framework of PTG is based on concepts familiar to clinicians as its roots are based in cognitive, behavioral, interpersonal, and existential concepts. We do not believe a PTG model of care should replace evidence-based therapies, but rather integrated into their delivery.

The people component of the program is arguably the easiest to integrate into traditional mental health settings. BCR staff are trained in basic techniques such as active listening and reflection. They are taught how to convey genuineness and compassion and are regularly reminded of the importance of being non-judgmental. These are all basic skills clinicians should already possess. However, as psychologists who have been involved with training and supervision of therapists for many years, we have grown to believe that these basic yet powerful techniques and approaches to patient care are often overlooked, forgotten, or ignored. One can generate many hypotheses as to why this has occurred, but we believe there is a direct negative correlation between these skills and the proliferation of manualized therapies.

Many of the program interventions used in Warrior PATHH are based on sound psychological principles. For example, psychoeducation about trauma and its effects is often the initial phase of psychotherapy. The ability to engage in emotional regulation, whether it be through meditation, mindfulness, or a variety of relaxation techniques are key to dealing with the intense psychological and physiological reactions associated with past traumatic events. And self- disclosure and adaptive narrative development are cornerstones of all trauma-focused therapies and many non-trauma focused therapies.

Lastly, supporting trauma survivors in the creation of a new “mission” in their posttrauma lives mirrors the important aspect of psychotherapy in which patients are supported in their desire and tendency to grow and mature as humans. Helping the veteran find meaning and purpose in his or her life is arguably the greatest collaborative goal that can be set and worked toward in therapy. This is perhaps a key guiding principle in this program. Veterans are expected to see their continuing value to their families, communities and country in the service they can provide because they have a growth perspective on the adversity they have experienced. At BCR, veterans are not merely healed from symptoms, but are encouraged to utilize their considerable strengths on continued meaningful missions of service.

Conclusion

We hope that the example of the BCR program will encourage those who work with veterans and other trauma survivors to look beyond the narrow focus on evidence-based treatments to consider the broader possibilities of healing that lead to lives that are truly meaningful in spite of the tragic parts of the life story. With this perspective, our veterans are likely to be treated with more respect and encouragement and the outcomes for them will please them and their families, and inspire the rest of us.

28 References

Hoge, C. W., Auchterlonie, J., & Milliken, C. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA: Journal of the American Medical Association, 295(9), 1023- 1032.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351(1), 13-22.

Hoge, C. W., Terhakopian, A., Castro, C. A., Messer,S. C., & Engel, C. C. (2007). Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. American Journal of Psychiatry, 164,150–153.

Institute of Medicine. (2014). Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, D.C.: National Academies Press.

Kehle-Forbes, S. M., Meis, L A., Spoont, M. R., & Polusny, M. A. (2016). Initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic. Psychological Trauma: Theory, Research, Practice, and Policy, 8, 107-114.

Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., Young-McCaughan, S., Mintz, J., Williams, S. R., Arne, K. A., Breitbach, J., Delano, K., Wilkinson, E.& Bruce, T. O. (2015). Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. American Journal of Psychiatry, 172(5), 441-449.

Schnurr, P.P., Friedman, M.J., Engel, C.C., et al. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. Journal of the American Medical Association, 297, 820-830.

Steenkamp, M. M., Litz, B. T., Hoge, C. W., and Marmar, C. R. (2015). Psychotherapy for military-related PTSD: A review of randomized clinical trials. Journal of the American Medical Association, 314, 489-500.

Tanielian, T., & Jaycox, L. H. (Eds.). (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corporation.

Tedeschi, R. G. & Moore, B. A. (2016). A model for developing community-based, grass-roots laboratories for postdeployment adjustment. The Military Psychologist, 31(2), 6-10.

Westlund, S. (2015). “Becoming human again”: Exploring connections between nature and recovery from stress and post-traumatic distress. Work, 50, 161-174.

29 18-MONTH RESULTS

The initial pilots included 23 participants from four Warrior PATHH programs, run in

August, September, October, and December 2016. In order to create a more robust

number of respondents, we added four additional Warrior PATHH programs

(an additional 26 participants, increasing the total to 49 participants) to the program

evaluation, from January, February, April, and May 2017. The following pages detail

the program evaluation results for all programs.

30 QUANTITATIVE EVALUATION SYMPTOM REDUCTION

Instrument: PCL-5

Explanation of Instrument: The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 has a variety of purposes, including: Monitoring symptom change during and after treatment; Screening individuals for PTSD; Making a provisional PTSD diagnosis.

Rationale for Usage: Almost all traditional military and veterans clinical programs measure the presence and severity of PTSD and use it as a means of monitoring the efficacy of treatments specific for PTSD (e.g., prolonged exposure, cognitive processing therapy, eye movement desensitization and reprocessing). It is important that Boulder Crest do the same if it plans to draw comparisons between the efficacy of the Warrior PATHH program and traditional clinical interventions.

Comments: Reductions in PCL scores are substantial and clinically significant.

Average PCL Score

At 18 months, 54% reduction in PCL, well below clinical threshold. 50

40 CLINICAL PTSD THRESHOLD

0 Initial 18 Months

31 SYMPTOM REDUCTION

Instrument: DASS-21 (Depression Anxiety Stress Scale)

Explanation of Instrument: The short form of the DASS is a 21-item self-report measure with 3 subscales (Depression, Anxiety, and Stress), and includes statements that address how subjects have felt during the past week, such as “I found myself getting agitated” and “I felt that life was meaningless.” All items are rated on a 4-point Likert scale, ranging from 0 (“Did not apply to me at all”) to 3 (“Applied to me very much, or most of the time”). Together, the three subscales provide a summed score of overall distress (Cronbach’s α = .93). (Henry and Crawford, 2005).

Rationale for Usage: In addition to being a brief measure of the most common symptoms of psychological problems, the DASS also can indicate response to treatment.

DASS-21 Depression

At 18 months, 52% reduction in depression. 20

0 Initial 18 Months

32 DASS-21 Anxiety

At 18 months, 41% reduction in anxiety.

0 Initial 18 Months

DASS-21 Stress

At 18 months, 35% reduction in stress.

0 Initial 18 Months

33 SYMPTOM REDUCTION

Instrument: The Insomnia Severity Index (ISI)

Explanation of Instrument: The ISI assesses insomnia according to the criteria from the DSM-IV and the International Classification of Sleep Disorders. It is a 7-item self-report questionnaire assessing the nature, severity, and impact of insomnia in the past month. The specific items evaluate the severity of difficulties with sleep onset, sleep maintenance, and early morning awakening; sleep dissatisfaction; interference of sleep problems with daytime functioning; noticeability of sleep difficulties by others; and distress caused by sleep difficulties. A 5-point Likert scale is used to rate each item. (Morin, C.M., 1993).

Rationale for Usage: Sleep difficulties are not only debilitating in themselves, but may also be indications of stress, anxiety, etc. Warrior PATHH could help the many service members with sleep disturbances by providing a brief sleep hygiene component.

Insomnia SI

At 18 months, 39% reduction in insomnia. 15

0 Initial 18 Months

34 SYMPTOM REDUCTION Instrument: The Brief Michigan Alcoholism Screening Test (bMAST)

Explanation of Instrument: The Brief Michigan Alcoholism Screening Test (bMAST) is a 10-item test derived from the 25-item Michigan Alcoholism Screening Test (MAST). It is widely accepted as an acceptable measure of alcohol dependence.

Rationale for Usage: Alcohol abuse is common among service members who have not found other ways of coping with distressing posttraumatic stress symptoms, and this contributes to disturbances in relationships, reckless behavior and health problems. With training in better coping strategies, those participating in Boulder Crest programs will have an opportunity to change their patterns of alcohol use and abuse.

Brief MAST

At 18 months, 5% reduction in alcohol abuse. 10

0 Initial 18 Months

35 SYMPTOM REDUCTION

Instrument: Drug Abuse

Explanation of Instrument: Drug Abuse is a brief measure developed by Drs. Tedeschi and Moore for the PE.

Rationale for Usage: As in the case of alcohol abuse, the coping skills developed at Warrior PATHH are likely to make drug use less attractive, especially after refraining from any drug use during the time in the program.

Drug Abuse

At 18 months, 44% reduction in drug use.

.1 Initial 18 Months

36 SYMPTOM REDUCTION Instrument: Suicidality

Explanation of Instrument: Suicidality is a brief measure of suicide developed by Drs. Tedeschi and Moore for the PE.

Rationale for Usage: A sense of purpose and hope, and connections with others that reduce isolation are likely to be enhanced during participation at Warrior PATHH. These are factors that have been shown to affect suicidality.

Suicidality

At 18 months, 66% reduction in suicidality from low initial score.

1.6 1.4

1.2 1.0 .8

.6 .4

.2 0 Initial 18 Months

37 SYMPTOM REDUCTION Instrument: The Positive and Negative Affect Schedule (PANAS)

Explanation of Instrument: The Positive and Negative Affect Schedule (PANAS) (Watson, D., Clark, L. A., & Tellegen, A., 1988). The PANAS measures a variety of positive and negative affective states. The 10 items for positive affect are attentive, interested, alert, excited, enthusiastic, inspired, proud, determined, strong and active. The 10 items for negative affect are: distressed, upset, hostile, irritable, scared, afraid, ashamed, guilty, nervous, and jittery. This measure can be modified so that instructions can direct respondents to describe their affect over various periods of time.

Rationale for Usage: Warrior PATHH should be expected to not only reduce negative affect which is very distressing, but also to increase positive affect, which is associated with well-being.

Comments: For the PANAS Positive Affect Schedule, higher scores indicate progress; for the PANAS Negative Affect Schedule, lower scores indicate progress. PANAS Positive Affect Schedule

At 18 months, 24% improvement in positive emotions. 50 45 40 35 30 25 20 Initial 18 Months

PANAS Negative Affect Schedule

At 18 months, 25% reduction in negative emotions. 30

15 Initial 18 Months

38 QUALITY OF LIFE/STRESS MANAGEMENT Instrument: Couples Satisfaction Index (CSI)

Explanation of Instrument: Couples Satisfaction Index (CSI) (J.L. Funk & R.D. Rogge, 2007). The CSI was created from a number of existing measures of relationship satisfaction, resulting in a 32 item measure of intimate relationship satisfaction. A 4 item version was developed from this larger pool of items, using a 6 point Likert response format.

Rationale for Usage: The Warrior PATHH experience is likely to produce changes in relationship functioning such as empathy and disclosure that enhance interpersonal relationships.

Couples Satisfaction Index

At 18 months, 14% improvement in couples satisfaction.

100

10 Initial 18 Months

39 QUALITY OF LIFE/STRESS MANAGEMENT Instrument: Perceived Stress Reactivity Scale (PSRS)

Explanation of Instrument: Perceived Stress Reactivity Scale (PSRS) (Schlotz, W., Yim, I. S., Zoccola, P. M., Jansen, L., & Schulz, P. , 2011). This scale assesses an individual’s perceived typical response intensity across different potentially stressful situations in everyday life. The PSRS is a 23-item questionnaire with one overall measure of stress reactivity, and 5 subscales: Prolonged Reactivity, Reactivity to Work Overload, Reactivity to Social Conflicts, Reactivity to Failure, and Reactivity to Social Evaluation. It is based on an existing German-language instrument. It asks about a person’s general reactions to stressful situations he/she may have experienced in the past. Respondents answer on a scale from 0-2, with each set of three responses differing for each question.

Rationale for Usage: Emphasis at Warrior PATHH on positive coping strategies and affective control should diminish a tendency to respond intensely to various forms of everyday life stress.

Perceived Stress Reactivity Scale

At 18 months, 33% reduction in stress reactivity. 25

15 Initial 18 Months

40 QUALITY OF LIFE/STRESS MANAGEMENT Instrument: The Ego Resiliency Scale (ER89)

Explanation of Instrument: The Ego Resiliency Scale (ER89) (Block, J.,& Kremen, A.M.,1996). The ER89 is a 14 item measure of the ability to adapt level of control to situational context, or adaptive flexibility. People who are ego-resilient experience more positive affect, self-confidence and psychological adjustment. Responses are on a 4-point Likert scale.

Rationale for Usage: The Warrior PATHH program includes a number of components that can help participants to improve their ability to manage future life challenges.

Ego Resiliency Scale

At 18 months, 14% improvement in ego resiliency. 50

0 Initial 18 Months

41 QUALITY OF LIFE/STRESS MANAGEMENT Instrument: The Multidimensional Scale of Perceived Social Support (MSPSS)

Explanation of Instrument: The Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet, Dahlem, Zimet & Farley, 1988). The MSPSS is a 12 item measure of perceptions of support from 3 sources: Family, Friends, and a Significant Other. It uses a 7-point Likert scale.

Rationale for Usage: Warrior PATHH experiences allow people who may have isolated themselves to appreciate the importance of support from others, and to overcome some hesitancy in seeking support in their families and communities. Indications of perceived social support should predict good adjustment in the future.

Comments: Higher scores reflect more progress in MSPSS.

Multidimensional Scale of Perceived Social Support

At 18 months, 2% improvement in MSPSS scores. 80

0 Initial 18 Months

42 QUALITY OF LIFE/STRESS MANAGEMENT

Instrument: Physical activity

Explanation of Instrument: Physical activity developed by Drs. Tedeschi and Moore for the PE.

Rationale for Usage: Increased physical activity may increase energy, concentration, and emotional well-being. Warrior PATHH encourages physical activity due to the setting and the outdoor activities.

Physical Activity

At 18 months, 11% improvement in physical activity. 10

0 Initial 18 Months

43 QUALITY OF LIFE/STRESS MANAGEMENT

Instrument: Nutrition

Explanation of Instrument: Nutrition developed by Drs. Tedeschi and Moore for the PE.

Rationale for Usage: Attention to healthy eating at Warrior PATHH may affect the choices participants make and the eating habits they develop after returning home. Good nutrition can affect emotional as well as physical health.

Nutrition

At 18 months, 26% improvement in nutrition. 10 9 8 7 6 5 4 3 2 1 0 Initial 18 Months

44 QUALITY OF LIFE/STRESS MANAGEMENT

Instrument: Employment

Explanation of Instrument: Employment developed by Drs. Tedeschi and Moore for the PE.

Rationale for Usage: The Warrior PATHH program enhances some basic skills that can lead to increased self-confidence and ability to work successfully with others, and such skills can be expected to affect motivation to seek employment, success in employment, and satisfaction with employment.

Employment

At 18 months, slight reduction in employment satisfaction. 12

0 Initial 18 Months

45 QUALITY OF LIFE/STRESS MANAGEMENT

Instrument: Finances

Explanation of Instrument: Finances developed by Drs. Tedeschi and Moore for the PE.

Rationale for Usage: Good financial decisions are a goal of the Warrior PATHH program, and can reduce stress over time.

Finances

At 18 months, 12% improvement in finances. 6

0 Initial 18 Months

46 QUALITY OF LIFE/STRESS MANAGEMENT

Instrument: Legal Status

Explanation of Instrument: Legal status developed by Drs. Tedeschi and Moore for the PE.

Rationale for Usage: As a result of more positive living habits learned at Warrior PATHH, we expect that problems with the legal system would diminish.

Legal Status

At 18 months, no change in legal status.

0 Initial 18 Months

47 QUALITY OF LIFE/STRESS MANAGEMENT

Instrument: Medical Outcomes Study 36-item Short Form Health Survey (SF-36)

Explanation of Instrument: Medical Outcomes Study 36-item Short Form Health Survey (SF-36). Ware, J. E., & Sherbourne, C. D. (1992). The SF-36 assesses eight health concepts: limitations in physical activities because of health problems; limitations in social activities because of physical or emotional problems; limitations in usual role activities because of physical health problems; bodily pain; general mental health (psychological distress and well-being); limitations in usual role activities because of emotional problems; vitality (energy and fatigue); and general health perceptions. Participants are asked to respond to questions that ask how they have felt over the last week on Likert-type scales, some with five or six points and others with two or three points. The SF-36 has been widely used and has excellent psychometrics. Two summary scores are derived: the Mental Health Component Score and the Physical Health Component Score. We will use an abbreviated version focusing on physical health domains.

Rationale for Usage: The programming at Warrior PATHH encourages improved health behaviors, which may result in fewer health complaints, more energy, and less pain. Improved emotional states also allow for improved physical health and vice versa.

Medical Outcomes Study

At 18 months, 25% reduction in medical outcomes. 8

0 Initial 18 Months

48 POSTTRAUMATIC GROWTH & COGNITIVE FLEXIBILITY Instrument: The Posttraumatic Growth Inventory-Expanded (PTGI-X)

Explanation of Instrument: The Posttraumatic Growth Inventory-Expanded (PTGI-X) (Tedeschi, Cann, Taku, Senol-Durak, & Calhoun, 2016). The PTGI-X is a 25-item scale that measures the extent to which individuals report positive psychological change as a result of experiencing a traumatic event, and is based on the original measure (Tedeschi & Calhoun, 1996). The degree to which individuals experience change is assessed in five domains, which include: new possibilities (“I established a new path for my life”), personal strength (“I discovered that I’m stronger than I thought I was”), relating to others (“A sense of closeness with others”), spiritual- existential change (“A better understanding of spiritual matters”), and appreciation of life. The PTGI-X is based on the original 21-item PTGI except that it adds items representing existential change. It utilizes a 6-point Likert response format, with item scorings ranging from 0 (“I did not experience this change as a result of the event”) to 5 (“I experienced this change to a very great degree as a result of the event”).

Rationale for Usage: As a core basis of the Boulder Crest philosophy and program content, PTG must be assessed, and the use of the newly expanded version will allow respondents to consider the existential concerns that combat experience tends produce.

Posttraumatic Growth Inventory

At 18 months, 56% improvement in PTGI scores. 100

0 Initial 18 Months

49 POSTTRAUMATIC GROWTH INVENTORY - IN DEPTH

Spiritual/Existential Change

At 18 months, 78% improvement. 25

10 Initial 18 Months Deeper Relationships

At 18 months, 69% improvement. 25

10 Initial 18 Months New Possibilities

At 18 months, 58% improvement. 25

10 Initial 18 Months

50 POSTTRAUMATIC GROWTH INVENTORY - IN DEPTH Personal Strength

At 18 months, 36% improvement. 25

10 Initial 18 Months

Appreciation of Life

At 18 months, 26% improvement. 10

7 Initial 18 Months

51 POSTTRAUMATIC GROWTH & COGNITIVE FLEXIBILITY

Instrument: The Acceptance and Action Questionnaire II (AAQ-II)

Explanation of Instrument: The Acceptance and Action Questionnaire II (AAQ-II). The Acceptance and Action Questionnaire II (AAQ-II) (Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., & ... Zettle, R. D., 2011). The AAQ-II is a 7-item self-report questionnaire developed to assess an individual’s inability to change perspective and adapt to changing situational demands, or psychological flexibility. It uses a 7-point Likert scale.

Rationale for Usage: The Warrior PATHH program challenges beliefs about oneself, others, and the world, and would therefore support increased psychological flexibility. This flexibility is crucial in managing various life challenges.

Acceptance and Action Questionnaire

At 18 months, 32% improvement in ability to change perspective/psychological flexibility.

20 Initial 18 Months

52 POSTTRAUMATIC GROWTH & COGNITIVE FLEXIBILITY

Instrument: The Integration of Stressful Life Experiences Scale (ISLES)

Explanation of Instrument: The Integration of Stressful Life Experiences Scale (ISLES). The ISLES is a 16-item measure designed to assess the extent to which someone has adaptively integrated or made sense of a problematic life experience. Two subscales can be computed: Footing in the World and Comprehensibility.

Rationale for Usage: The difficult or traumatic experience of military service or other previous life crises must be integrated into a sense that these experiences can have a place in the overall personal narrative. Warrior PATHH encourages the consideration of various life difficulties within a meaningful and comprehensible view of self.

Integration of Stressful Life Experiences Scale

At 18 months, 23% improvement in capacity to integrate problematic life experiences.

30 Initial 18 Months

53 POSTTRAUMATIC GROWTH & COGNITIVE FLEXIBILITY

Instrument: The Self Compassion Scale-SF (SCS-SF)

Explanation of Instrument: The Self Compassion Scale-SF (SCS-SF) (Raes, F., Pommier, E., Neff, K. D., & Van Gucht, D). (2010). The SCS-SF was developed from the original SCS of 26 items published by Neff (2003). The SCS-SF is a 12 item measure of six aspects of compassion toward self: Self-Kindness, Self-Judgment, Common Humanity, Isolation, Mindfulness, Over- identification with failure. It is scored on a 5-point Likert scale.

Rationale for Usage: The Warrior PATHH experience is likely to produce a more compassionate view of self, as reactions to military service are normalized and a compassionate response is offered to each participant. Self-blame, guilt and shame are likely to diminish.

Self Compassion Scale

At 18 months, 22% improvement in self compassion. 50

30 Initial 18 Months

54 POSTTRAUMATIC GROWTH & COGNITIVE FLEXIBILITY

Instrument: The Gratitude Questionnaire-Six Item (GQ-6)

Explanation of Instrument: The Gratitude Questionnaire-Six Item (GQ-6) (McCullough, Emmons & Tsang, 2002) The GQ-6 measures the general construct of gratefulness with a 6 items. It uses a 7 point Likert response format.

Rationale for Usage: Gratitude has been associated with improved health outcomes, as well as mood. It is likely associated with aspects of posttraumatic growth such as appreciation of life. The Warrior PATHH experience provides an opportunity for participants to be grateful for the attention and appreciation they are shown during their retreat, and this may prompt a more grateful approach to other aspects of their lives, and support altruistic missions.

Gratitude

At 18 months, 10% increase in gratitude. 40

30 Initial 18 Months

55 POSTTRAUMATIC GROWTH & COGNITIVE FLEXIBILITY

Instrument: Active Reading

Explanation of Instrument: Active reading. A question about reading habits will be developed by Drs. Tedeschi and Moore for the PE.

Rationale for Usage: Recent research (Tsai, El-Gabalawy, Sledge, W., Southwick, & Pietrzak, 2015) has shown that those who have experienced combat who actively engage in reading have better outcomes and this has been associated with growth after trauma. The Warrior PATHH experience may produce more openness and interest in learning and knowing.

Active Reading

At 18 months, 40% increase in reading. 2.0

1.0

0 Initial 18 Months

56 POSTTRAUMATIC GROWTH & COGNITIVE FLEXIBILITY

Instrument: Core Beliefs Inventory (CBI)

Explanation of Instrument: Core Beliefs Inventory (CBI) (Cann, A., Calhoun, L. G., Tedeschi, R. G., Kilmer, R. P., Gil-Rivas, V., *Vishnevsky, T., & Danhauer, S. C., 2009). The CBI is a is a 9-item inventory that is designed to assess the degree to which a specific traumatic event has disrupted one’s core beliefs about oneself, others, and the world. Items are rated on a 6-point scale ranging from 0 to 5 and include statements such as “Because of the event, I seriously examined my beliefs about my relationships with other people” and “Because of the event, I seriously examined my beliefs about the meaning of my life.”

Rationale for Usage: Core belief disruption is commonplace in those with combat experience, and this is a precursor to PTG. Participation in the Warrior PATHH program will challenge and help to reconstruct core beliefs.

Core Beliefs Inventory

At 18 months, 9% decrease in disruption to core beliefs. 50

0 Initial 18 Months

57 QUALITATIVE FEEDBACK Please share your thoughts about the effectiveness of the Warrior PATHH program

• “Everyone’s sincere dedication and love for us was amazing.”

• “Amazing, enlightening, powerful, mind and heart opening. I am so very thankful for this experience and opportunity. I had no idea that anything like this even existed. YOU guys are on a path of wonderful and tremendous change. I hope many others strive to emulate what you have created. Thank you.”

• “This program works. Please continue to be the Vanguard and Leader for PTG...You are doing amazing work at BCR, please don’t ever give up!! Thank you!!”

• “This should be standard for all Soldiers and Veterans!”

• “This program is life changing. The ability to take a week out to work through what happened to you in life and how you can use those struggles to thrive in life was amazing.”

• “I have been struggling with what I thought was wrong with me for quite a while now. I have had various forms of treatment to include physical and mental health and nothing has allowed me to see what has happened to me before I even went in to the military and how I have never processed any of the stress or pain from that or anything after that until now. Learning about my past was a crucial part to understanding my natural way of thinking and learning practical ways to manage stress every day vs. just taking medication is so exciting!! I have felt the biggest weight lifted off my heart this week and feel so excited for real change in my life, in my work, in my relationships and most importantly as a mom to impact the future.”

• “As a skeptic, I came here with the notion the program would be like a “bandaid.” I would be given an “aid bag” to fix myself. I had anxiety on the 3rd day for this reason. But I could not have been further from the truth. Not only was I given the right practices to be effective and successful I was reassured that I can do this. The staff at BCR genuinely care about each one of us. The love and kindness that comes from this space is phenomenal and exceptionally effective. Thank you so much for this gift.”

• “I’ve been to 4 treatment centers before this one. This is the only one where I felt built up at the end, and where I left with a plan, and a plan I could actually implement. I’ve gained relationships that I wouldn’t have gained otherwise and I feel these are relationships that will last a lifetime. BCR feels like the closest place to a family. I came in this program believing I was a victim. I’m leaving this program knowing I’m a warrior that can handle these emotions, situations and life it itself. I was unsure before. This is by far the most beneficial treatment I’ve gotten. This program should be offered for incoming military personnel as a way to establish resiliency BEFORE serving so there are less cases of PTSD, depression, anxiety, etc.”

• “This past week has truly been a remarkable experience. What I really appreciated at this Retreat was the emphasis more on the person’s background coming from their childhood instead of solely focusing on their military career and combat deployments. I find it is extremely

58 easy to get caught up in the war stories and use your deployments as almost a sense of validation to the community because it’s something which people look for to give them that advantage so to speak compared to the next person when in fact, it has little to do with that and that comes down to ego. The staff in this program are exceptional. Being able to find a group that works well with each other and can show that sense of camaraderie to their participants is important because we need to see a united front in people that want to help us. Having staff that take an interest in who we are as a person and seeing that there are people that care about you, was especially crucial for me because I tend to think I go throughout my life alone and have embraced that and taken a sense of pride in the fact I felt like I never needed anyone and better yet, people always come to me. All the activities were so special, in particular the equine therapy, the archery and a lot of the indoor modules. I want to thank everyone for their role here at this Retreat and I will never forget any of this from this moment on. Also a thank you for the wonderful food, hospitality and just welcoming feeling like we were the primary guests here and people wanted to take care of us. It was something very different and I was not used to experiencing this one bit.”

• “Words cannot express how grateful I am to the staff of BCR. My time here has been life changing, and I’m confident I can lead a much more productive life with the skills and advice imparted here. The facilities are world class. Simply amazing!! The staff is incredibly thoughtful and caring and I appreciate the emotional investment that they devoted to our success. I loved the detail that was apparent at every level. I think that everything was generally amazing. I simply can’t thank the BCR folks enough. Ken and Julia have hit a homerun and this gift will reap untold dividends. Thank you!!!!!

• “I had no idea how much I was lying to myself and therefore lying to others. I may not have liked to hear the truth, but I’m certainly grateful for the opportunity to hear it in a safe and supportive place. Now I can fix it. The training environment allows us to figure out what and how we need to work on without judgement, as well as the opportunity to practice those skills in support of reintegration. The deliberate planning and design is both flexible and all inclusive, allowing each individual to learn what they needed to and take away what they choose to.”

• “This program has not only been a game changer, it has been a lifesaver. The key take away for me is... there are people who truly and genuinely care. I am not alone in finding peace with my experience. I look forward to continuing walking on my journey in life and sharing my experience with the Boulder Crest family. It’s my story to tell, one which may help in the healing of others. Life happens to us all. Life is an amazing gift. I am happy because of my struggles! I will wake up each day and own and crush it!!!”

• “This program has does wonders for me in just a week’s time. It’s so amazing what we can do when we put the phones down, tune out every day distractions and really focus. I was unsure of myself and confused but attending the PATHH program really helped me to put things in to better perspective.”

• “PATHH has changed my life and allowed me to be the person I’ve always dreamed of being. It has placed the pieces of my heart exactly where they needed to go and provided me guidance. It saved my life. I found this program to be exactly what I knew I’ve needed. A safe place where I could re-BZO who I am and the person/husband/father/citizen I want to be as I move forward through my life. The TM and the childhood session were very enlightening for me. I think a

59 children-of-Combat Vets program and/or parenting program or module would be something I am in need of. Also more modules that focus on the financial part of the triangle. Thank you for everything. I feel extremely lucky to have met all of the staff and PATHH participants.”

• “This experience makes me wish that it was available to me earlier, instead of pushing medications as an only answer. I want to build my own Boulder Crest and lead others out of darkness.”

• “I now feel like I can go home and start to think before I act. I am looking forward to using the skills I learned here at home. It will be interesting to see home the first few days go. Thank you for my time here. being with my fellow techs was a great time.”

• “Amazing program that taught me a lot about myself and others.”

• “This program is unique and incredibly effective. Not only did it help me to better understand who I really am, which not who I thought I was, but it helped me to better reconnect to the world and give me a direction to go with my life.”

• “I firmly believe that the PATHH program helped me to understand a tremendous amount about myself. After 19+ yrs in a combat unit with multiple deployments and being well embedded in the combat veteran community, this is the first time I have seen positive results with a plan and direction for myself and others attending the training to move forward.”

• “PATHH gave me back a sense of self worth. I have realized how much value I have and that I have a lot to offer the world: to lead and to inspire.”

• “This program has been extremely helpful in allowing me to refocus on what is important in life. Going through the program alongside those with whom I served was an invaluable experience. The value of understanding what got me to where I am; the focus on reevaluating priorities and the ability to reconnect with inner self and nature were very helpful to me. I feel that this experience has enabled me to build confidence about the steps I need to take to become the man I want to be. It was a perfect pause and wake up call.”

• “It was an amazing experience! I know plenty of people, both veteran and civilian who could use this program. The practices you guys provided can not only help people, but can change the world! Thank you!”

• “Great place definitely need more around the country.”

• “The fact that the staff veteran or not are so damned genuine. The fact combat veterans are a majority is extremely important to help open, but on the other side the civilian staff are such amazing people, and while it is their job I did not encounter one fake moment or see anyone at anytime not completely engaged in helping me and that made it much easier to be able to be honest with them and myself. Thank you so much for everything.”

60 Please describe what aspects of the Warrior PATHH program you found to be most helpful in your growth?

• “TM, breathing and actually talking in a group.”

• “TM, the horse therapy and group sessions. The MOS was a real eye opener too.”

• “Newfound brotherhood to lean on.”

• “Meditation, reset sleep schedule, exercise, return to proper diet.”

• “TM. MOS. PTG.”

• “The continuous message that I have a choice to feel the way I do, the non judgment of the women I’m in the program with, the ongoing communication and goal reaching.”

• “The practice of TM combined with daily gratitude have been very beneficial in shaping my daily actions and thoughts. Also, having the week intensive program was crucial in stepping away from the distractions of life and really addressing the problems in my life and then building practices to adapt and get back to my true self.”

• “Realizing my worth as a person was the biggest thing I took away from being at PATHH. I have been repeatedly making the same choices in regards to relationships and now I finally see clearly what I was doing and what the opposing partner was doing. Learning to be content on my own and deviate away from the co-dependency is something I will continue to work on. The meditation and journaling are two major aspects as well however there are times when I find it hard to meditate for the second time in the day.”

• “The connection with my peers and their experiences.”

• “Learning so many different ways to deal with stress WHEN it comes not if. TM was a huge help as I imagine that is the thing that is having the most impact on my sleep and energy throughout the day. I’ve also used grounding every morning since I came back to set the tone for my day and give myself some control over how I want to think about things. Keeping in contact with both the staff and our team has been awesome for accountability and just to have people you know you can talk to and will support you and also kick you in the butt if you need it. Outside of all of these techniques that I’m using daily, probably the biggest thing I got out of the program was finding honest forgiveness in my heart for those who have wronged me and I feel set free from a weight I’ve been carrying for a few years now. It has absolutely changed my life and will probably have a pretty big impact on the lives of my family and friends who’ve held on to same of these same burdens for me.”

• “The systematic process of tearing down and building back up. The revel of how we have been trained to be and think since childhood. The freedom to feel, be sad, be scared and cry. The creation of a real network of people that are real and truly care about me.”

• “Being able to open my heart to strangers whom I immediately felt a connection with saved my life. The PATHH program allowed me to find the places of my heart I thought I’d lost forever. TM, expressing my feelings through therapy, archery created moments of clarity.”

61 • “The experience of being present in the moment, reconnecting with myself, and being recognized for who I am.”

• “Connecting with nature and being able ot step outside myself. It was nice to see how other people view me. It was a eye opener.”

• “Perspective... I see the tree of life in each bare tree that I see. Not because it’s there, rather because, I view life with a different perspective. That’s progress. Strength, enlightenment through all my scars and struggles. Life is beautiful. I am able to understand that more, sense my journey at BCR. I have a smile, pep in my step and excited about the next chapter in my life after retiring from active duty. My hope is to truly help other veterans rise through their struggles.”

• “Learning about my past and how it, and my military training, make me who I am today.”

• “TM has been big, and taking the time to remember how to live well. Focusing on family and the time we have today, versus what we didn’t do yesterday or what needed a to be done tomorrow.”

• “The chart that answers the “Why” question. It is not what is wrong, it is what has happened. I feel that helped a lot. Still not sure why but it felt like a switch was flipped that day.”

• “The comradery between the group.”

• “I find that the meditation helps a lot. The concept of what happened not what’s wrong with me.”

• “TM, feeling like part of a team, gaining support of others who attended. Family genome, journals.”

• “Going through the program with those I served alongside and developing a deeper bond that I could have imagined previously.”

• “For me, TM has been the most rewarding part of the program. By implementing this practice in my life, it has provided clarity with stressful situations and solidified my spiritual connection. The explanation of my experience while in the military came in second. When Josh explained how this experience conditioned my thoughts and behaviors, and the fact that I continued to think and act the same way several years after I separated, it really had a profound impact on the way I look at life today.”

• “The lessons at Boulder Crest are self evident, after being around that much death and killing I lost sight, I even lost sight that it was all that stuff that made me feel that way. I took on guilt shame, I felt I shouldn’t have survived. Having someone to sort of pick you up and dust you off a bit and explain why you feel that way and to show the way out of it is huge. I don’t want to go back to the drinking and not sleeping, the self loathing and self neglect. The reading and morning gratitude and little things you forget about, the nutrition class, and I was extra lucky because I had my brothers with me.”

• “Positive approach to everyday. Healthy eating habits, TM, and Yoga.”

62 Please describe what aspects of the Warrior PATHH program you found least helpful in your growth and recovery. Please be specific. Warrior PATHH program.

• “Not applicable.”

• “Nothing.”

• “Specific ocusf on childhood trauma.”

• “I can’t. I think each part is critical to the overall success of the program.”

• “Nothing.”

• “There wasn’t a moment of PATHH that did not help in some way. Every aspect brought me back to life.”

• “The implementation of goals that support taking home the lessons learned is an important topic and could be more effective.”

• “When we did the drawings on the canvas, I really didn’t get anything out of that. Sure it was fun, but not very effective for me.”

• “None. its all be extremely helpful. I was so desperate to get healthy mentally. I embraced all aspects of Warrior PATHH. I dove in, gave a 100%. They say once you hit rock bottom, you’ll know and that’s when you are willing to change. HA. I hit the bottom and now am moving back toward the TOP! Winning.”

• “Role playing and pretending to be each others’ wives.”

• “Nothing. I have never experienced anything like it before.”

• “Arts and crafts stuff.”

• “None.”

• “Each program aspect was very well thought out.”

• “The journaling and these surveys that ask the same question over and over.”

• “Goal planning. I think that it is an important aspect to make yourself better. However, their method didn’t seem very productive for me.”

• “These surveys, seriously you guys got it, but damn these surveys.”

• “I really don’t feel that there was any aspect of PATHH that wasn’t helpful, I just use more aspects on a daily basis than others.”

63 In what ways can Boulder Crest further support your growth and recovery?

• “Just the constant check ins and motivations from the staff.”

• “Nothing currently.”

• “As of now I don’t see much else. When I was going through a stressful situation, BCR staff was there for me to help support me through this and giving me excellent advice and a listening ear. Also maintaining the relationships with the other PATHH members since leaving has been a huge help for me.”

• “Everything is much more than I could ask for - the follow-up calls and counseling is very, very helpful.”

• “One area that I really need a push in was my physical fitness that I sort of put on the back burner in life and felt like I got too far behind to start again. I am looking forward to videos for TRX which I’m still using since coming home but starting to forget all the moves we did with it. I would also love to see some daily/weekly ideas for grounding like we had while we were there like a thought of the day or post.”

• “I would like to see a ‘reunion’ of PATHH graduates; mixed gender even. Maybe a self funded get together so we can meet other graduates and people on the path with us.”

• “Continue to be in contact and more contact with animals.”

• “Boulder Crest Retreat continues to love and support me - there isnt anything more they could be doing it, they are just doing it.”

• “Following up with scheduled sessions and virtual team sessions (maybe ID a participant “team lead” that is willing to coordinate logistics?)”

• “It would have been nice to be able to ride the horses when we did the equine session.”

• “Hard to think of any. Honestly, for me. Am putting in the work, BCR does their check ins, they respond to emails and texts. That’s enough for me, to know someone out there truly and genuinely cares.”

• “How about touching on the importance of gratitude? Perhaps attendees could be provided with thank you notes? I have written TYN’s to the ladies who sewed the bags, staff and Ken and Julia and Lauri. This would be a nice touch that we could do on our own time in the cabins. Postcard(s) in the desk? Talk to attendees about being debt free.”

• “Give us more of an idea about what obligations we have after we leave so people who are horrible with calendars and schedules won’t stress about meeting obligations. If you are having trouble getting people to complete the surveys, you can do a lottery. If people return the survey and three days they get two tickets if they return in a week they get one ticket for a prize? BCR swag!? Make instructional books on the things we learned. Yoga poses? Or privately (versus publicly) provide a resource on the website? Exercises. Etc.”

64 • “Keep following up with me.”

• “Bring my wife and I together on a program that will help us connect on an even bigger and deeper level.”

• “With follow up and support. Knowing that if I can’t get the answer or support from my group, I can reach out to the BCR Guides.”

• “They have been very helpful.”

• “I’m looking forward to staying in touch with boulder crest and participating in future programs. I think reunions for the groups would benefit a lot.”

• “Staying in contact with me.”

• “None.”

• “Continue with check ins - help coordinate TM training for spouse.”

• “Continued connection, mentorship, guidance, and the occasional motivational/reminder that keep me centered and focused on what’s important.”

• “To keep bringing the message to other veterans and help as many of us that you can because it really had a dramatic impact on me, and too many are suffering thinking they are supposed to feel that way.”

• “Continuing brotherhood and accountability Education in regards to Veteran based/non-profit organization for this is what I wholeheartedly want to do as my profession in the future.”

65 Do you feel that the help you received at Boulder Crest for your emotional needs was equal to, worse than, or better than the help you received at other places (VA, military treatment facility, private organization)? Please explain why.

• “The best that I have ever had...truly.”

• “Better than anything I’ve ever done for me. It has changed my life. I look at things much differently now.”

• “Hands down better. BCR treated me not like a troubled patient.”

• “PATHH program is far superior to anything the V.A. has currently. It is my humble opinion that this program should be implemented into the military to help prepare all soldiers for civilian life.”

• “Better. The VA is stuck between a rock and a hard place because they have to help in a way that is double edged. It’s nice to have a single edged program.”

• “Way better.”

• “I have not had treatment at other places.”

• “This was the first real ‘therapy’ treatment I have ever received so I don’t have anything to really compare it to. But I will say that BCR absolutely has helped me tremendously. There are so many things I knew about myself and what I was doing as a result of my past but being able to openly discuss it in a safe area with other people who were free of judgment and instead offered nothing but support and words of encouragement, has changed my life dramatically. Even though I still feel sad some days and am struggling from time to time with my stressors, I know deep down that everything is going to be alright and I know how strong of a woman I am and will continue to be strong and know what I am worthy and capable of.”

• “Better because of the humanity, patience, respect incorporated into every interaction.”

• “SO MUCH BETTER! I’ve gone to several different places to seek help with pain, memories, flashbacks, hypervigilance and somehow by not even talking about our specific trauma, Boulder Crest was able to do what no one else has - allow me to be ok with not understanding it, forgive those who hurt me and find joy in the things I do have.”

• “This is the first time I have actually accepted help. I though I was pretty good at ‘dealing’ on my own. I am so grateful this was my first help.”

• “100% better.”

• “Boulder Crest retreat gave me my soul back by loving all the pieces of me I thought were long broken.”

• “Far surpassed any other experience or expectation. There is a personal impact that has created an effect in every aspect of my life.”

66 • “Yes, I have been to many therapeutic retreats and counseling sessions, but Boulder Crest is the only one that had a real effect on me. My life is forever changed since leaving there. You touched on every aspect of the human body...MIND, BODY and SOUL.”

• “Far better. BCR is light years ahead of the entire VA community. The Drs, Generals, CSM and overall leadership changes. However; the mentality has NOT changed. Their solution is short term immediate solutions to long term quality care. VA stand point IS, return the military member back to the fight. but at what cost. The real issues are NOT addressed, nor are they adequately provided with the tools, care, treatment to be physically and mentally healthy. The military is too focused on quantity vs the quality. 20 veteran suicides a day, is a direct correlated indicator VA is missing the mark. We discuss medicine mills in the civilian sector, yet in the military sector we have body mills. Meaning, diagnosis or not diagnosis the military member, but end state, return the military member back to their unit. 2nd and 3rd order affect of that is, the long term affect it will have on the military member and their family, due to them not receiving the CORRECT, ADEQUATE, EFFICIENT, QUALITY care they need the first time! My recommendation that should be mandated and leaders held accountable; Military Members cannot PCS, ETS, retire while undergoing chronic medical concerns ie, TBI, Behavioral Health, life threatening disease, cancer, leukemia, etc! Far too often military members fall through the cracks due to constant rotation through PCSing, ETSing, Medical Boards, Retiring. The medical concerns, issues are not addressed. We are doing a GREAT disservice to men and women who volunteered to protect our great nation. We owe them nothing, but what they have EARNED is; quality, concerted effort, efficient, effective medical care. BCR for me has filled that gap tremendously. It has to be effectively articulated to Senior military leadership, that what they are actually be briefed is NOT the reality on the ground. Too many are losing their battle, merely because someone General or Senior CSM don’t want their PowerPoint presentation to reflect the TRUE PICTURE!”

• “Way better overall. I’m not really sure why. Different perspective? I did derive great benefit from private therapy, but little benefit from VA stuff.”

• “Better.”

• “It has been better then all other routes thus far. It connects with you on a more deeper self level.”

• “I have been to NICOE at Walter Reed and through BTRIP at Portsmouth Naval medical center. Each of which felt like there was so much info being given to the group and nothing directly focused on the individual. PATHH was focused on the individual and adjusted as needed. There was less “by the book” teaching.”

• “I’ve never had any other treatment to compare too. I think this is definitely better than any military references that I have come across in the past.”

• “Best yet. The program felt like for the 1st time it was designed for combat veterans. The wording used and the introduction to our new team of brothers. Veterans need two things to be successful . 1. A mission 2. A battle buddy. Boulder Crest gave me both of those.”

• “Better than - far more tailored and culturally competent. Focused on helping me understand the source of the challenges I face rather than just attempting to treat/mask the symptoms.”

67 • “Better than the VA. Needs to be more BCR around for veterans.”

• “There is no comparison between these entities, the relationship is nonexistent. The VA and military treatment facilities are decades behind how to actually treat returning combat vets. Had I not gone to BCR, I would still be a miserable, disgruntled “vet”, wondering what I am going to do with my life. Thanks to this program, I feel like I have truly returned home.”

• “There was absolutely no comparison between what the VA does and Boulder Crest, I never got anything out of the VA besides money, they do pay me. But therapy wise, nothing. It could have been I wasn’t ready, but there is a world of difference in the methods as well.”

• “I definitely believe that the help I received from BCR far outweighed any help that i have received from any other source.”

68 Please provide any specific guidance, advice, or feedback you’d like to give to the Boulder Crest staff about your experience.

• “I am so very grateful for the staff and the overall experience at BCR. Each person took an interest in the PATHH members and really made us feel extremely comfortable with the tough situations we have dealt with in life and still were dealing with while coming through BCR. The fact that I have never had mentors before and came out having 3 mentors which I feel I can reach out to at any time, and have had my mentors support and advice upon leaving BCR means the world to me. I am so appreciative of that and with the fact that the staff saw my worth as a person and who I was and continuously made me feel like such an amazing person. Sometimes I know we realize that with a certain past and coming through it on the other end it can be hard to really see our own strength, and hearing it from the staff members about the person I am today and their positive feedback was truly eye opening for me. Especially when it comes to men, I have struggled tremendously. Relationships for the last 5 years have been a mess and after BCR, I absolutely know without a doubt that I now need to set my own boundaries and ensure that I get the respect I deserve from someone who claims to love me. Thank you all so much!!!!”

• “This was a life changing experience that I hope more and more veterans can attend. The staff is the perfect mix of awesome from typical military personalities to quirky hipsters and even deep thinkers and feelers. All of the activities were spot on, the conversations were deep and while it was an intense program, I felt like I walked away with at least a year’s worth of therapy! Keep doing what you’re doing! Thank you for reminding me of all the good I have in my life and all the good I have to give to others.”

• “I am so honored to know each one of you. I am so grateful everyday for what you are doing and the love you gave and showed me. Thank you. P.S. can there be a few more female PATHH’s offered. I have a list of over a dozen women who need this training. :)”

• “I love you all, deeply and truly. I wouldn’t be here if it weren’t for Boulder Crest Retreat and its amazing staff of super humans <3 I love you guys!”

• This experience has changed my life in a way that I didn’t know needed to be changed. Over the past month my personal perspective and priorities have shifted which have shifted my professional objectives and the impact that I want to have. Because my perspective has widened I am able to see opportunities on all fronts that I was previously closed off to. Thank you for the wake up call.”

• “I really have no other feedback. It’s definitely an experience I will never forget.”

• “I very much appreciate the time, effort and energy that each staff member invested into my well being and helping me. I’m extremely grateful for the opportunity and it is my goal in life to repay these good deeds. Thank you.”

• “It was a great experience.”

• “It was great.”

69 • “Another facility with a direction of what life is after the PATHH program, options to integrate in facilitating others to teach the PATHH program in local community.”

• “Keep it coming.”

• “I loved it. Met some great people and would like to see and help with future expansion projects.”

• “Simply, THANK YOU!!!”

• “Very grateful to all of you.”

• “Highly recommend bringing groups that have served together to experience PATHH together. Grateful and really enjoyed the staff and experience.”

• “You guys (and gal) were nothing less than outstanding! Words cannot explain the gifts you made me realize where there all along. If only there were more programs like yours around, the world would be a better place! I am truly grateful for everything you have provided. Thank You!”

• “Thank you very much for opening my eyes back up.”

70 ABOUT THE BOULDER CREST INSTITUTE FOR POSTTRAUMATIC GROWTH For the past five years, Boulder Crest has worked tirelessly to develop a new, innovative, and effective approach to times of struggle — one predicated on hope, growth, and 30 years of science on the subject of Posttraumatic Growth. This approach addresses the stigma associated with seeking help, and enables people to not only feel better, but to do better — by transforming their struggle into profound strength, lifelong growth, and a commitment to serving others.

Our approach has been piloted and proven at Boulder Crest’s two Posttraumatic Growth Academies — Boulder Crest Retreat Arizona and Boulder Crest Retreat Virginia — working with combat veterans and their family members, and first responders. These communities reflect some of the hardest hit with respect to mental health, and feature suicide rates that far exceed the general public.

Given Boulder Crest’s remarkable success to date, and in light of an epidemic of suicide and hopelessness afflicting the entirety of American society, it is clear that the Boulder Crest model must be scaled. To that end, Boulder Crest established the Boulder Crest Institute for Posttraumatic Growth.

The Institute’s vision is to develop, deliver, study, and scale Posttraumatic Growth-based solutions to times of struggle, including anxiety, depression, PTSD, and suicidality. Our mission is to ensure that all those who struggle have the opportunity to transform their struggle into profound strength and lifelong Posttraumatic Growth. Our work and beliefs are exemplified by our credo — Vis A Proelio — a Latin phrase meaning from the struggle comes strength.

The Institute’s four areas of operation — Training, Technology, Research and Evaluation, and Social and Policy Change — provide a platform for scaling our PTG and PATHH work nationally and internationally, and offering training programs embedded within large scale organizations, including the VA, Department of Defense, and mental health community.

71 “Struggle is the story of every great leader, every great man, and every great woman. Through encountering obstacles, heroes are tested and forged into becoming the great, authentic human beings they are destined to be.

Your birthright is to go through the crucible and be forged in the fire. It’s your birthright to return from struggle without resentment or hostility, but with the goal of serving others. It’s your birthright to rise from the ashes with a sense of honor and integrity that allows you to be a leader in your own life, and the lives of your family, community, and country.”

Ken Falke Boulder Crest Founder Josh Goldberg Co-Founder and Executive Director Boulder Crest Institute Authors of Struggle Well: Thriving in the Aftermath of Trauma

72 “AS IN WAR YOU HAVE BEEN GOOD SOLDIERS, SO IN PEACE YOU WILL MAKE GOOD CITIZENS.” — GENERAL WILLIAM SHERMAN

Warrior PATHH is the nation’s first-ever program designed to cultivate and facilitate Posttraumatic Growth (PTG) in combat veterans, and train these remarkable men and women to transform times of deep struggle into profound strength and lifelong growth. Over the course of 18 months, beginning with 7 days of immersive and intensive training, students are able to make peace with their past, learn to live in the present, and begin planning for a great future – full of passion, purpose, and service – here at home.

“Warrior PATHH proceeds through the intervention steps described by Tedeschi and McNally (2011), and Calhoun and Tedeschi (2013), to facilitate Posttraumatic Growth. These steps derive from the model of the Posttraumatic Growth process that is well-validated in research studies of military service members and other trauma survivors.” – Dr. Richard Tedeschi, Psychologist and Father of Posttraumatic Growth

“In just 2 days, Warrior PATHH makes breakthroughs that take the average medical model 12-14 months.” – Dr. Bret Moore, Former Army Psychologist

“Words cannot describe the effect and internal shift inside. I am, for the first time in my life, not at war within. The peace and calm feeling is foreign to me entirely, but wonderful. Here, you have discovered how to give a person their soul back.” – Warrior PATHH Graduate